https://leader.pubs.asha.org/article.aspx?articleid=2615527Judge Sets Requirements for Education Debunking Medicare ‘Improvement Standard’The federal government must do more to educate Medicare decision-makers that improvement in function is not a requirement for skilled-care services, including speech-language and swallowing treatment, according to a federal judge’s February ruling. The order relates to the 2014 settlement agreement in the “improvement standard” case (Jimmo v. Burwell), which ...2017-04-01T00:00:00News in Brief

The order relates to the 2014 settlement agreement in the “improvement standard” case (Jimmo v. Burwell), which underscores that Medicare must cover skilled nursing and therapy to maintain function or slow deterioration. In adopting a “maintenance coverage standard,” the settlement required Medicare to remove the “improvement standard” from its policy manuals and educate Medicare contractors and providers about the change.

Despite the education provided by the Centers for Medicare and Medicaid Services (CMS), many Medicare contractors and providers have continued to require improvement as a condition of continued coverage.

The original plaintiffs in the suit—the Center for Medicare Advocacy and Vermont Legal Aid— returned to court in 2016, claiming that Medicare had not implemented the provisions of the settlement. The federal judge overseeing the settlement agreement found in favor of the plaintiffs in August 2016, and outlined a specific corrective action plan in a February 2017 ruling.

By Sept. 4, CMS must:

Publish a new CMS webpage dedicated to Jimmo.

Publish a corrective statement disavowing the improvement standard.

Post frequently asked questions.

Provide new training for contractors making coverage decisions.

Conduct a national call to explain the correct coverage policy.

Significantly, the court largely adopted the wording of the plaintiff’s corrective statement over that of the government. The corrective statement says, in part, “The Centers for Medicare & Medicaid Services reminds the Medicare community of the Jimmo Settlement Agreement (January 2014), which clarified that the Medicare program will pay for skilled nursing care and skilled rehabilitation services when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration.”

It also states that “The Jimmo Settlement may reflect a change in practice for many providers, adjudicators, and contractors, who may have erroneously believed that the Medicare program pays for nursing and rehabilitation only when a beneficiary is expected to improve. The Settlement correctly implements the Medicare program’s regulations governing maintenance nursing and rehabilitation in skilled nursing facilities, home health services, and outpatient therapy (physical, occupational, and speech) and maintenance nursing and rehabilitation in inpatient rehabilitation hospitals for beneficiaries who need the level of care that such hospitals provide.”